“I was gratified to be able to answer promptly, and I did. I said I didn’t know.” --- Mark Twain
“The only good is knowledge and the only evil is ignorance.” … Socrates
“Tis better to be silent and be thought a fool, than to speak and remove all doubt.” … Abraham Lincoln
There are many components of the didactic curriculum for the surgical residents. The agenda of conferences has been designed to provide a balanced educational experience to supplement the residents’ clinical experiences. It is expected that all surgical residents will attend conferences except in the case of surgical emergencies. With regard to residents on surgery specialty services and surgery specialty residents on General Surgery services, the following guidelines will be followed:
1) When on the general surgery service you should go to General Surgery conferences. You may attend your “home specialty” conferences if they do not conflict with morning rounds.
2) When on the sub-specialty service and this service is the resident’s specialty then the residents are allowed to attend the specialty conference and miss General Surgery conference.
3) Orthopeadic residents are allowed to attend their Monday morning Orthopeadic conferences during General Surgery rotations.
4) All residents may miss General Surgery Conferences if they are involved in an OR case that is considered an “index case” and will contribute substantially to their operative experience log.
Attendance at a rate below 80% will prompt a review by the Governance Committee.
Service Based Attending Rounds
Every Monday morning at 7:00 AM, the following teams will meet to discuss the cases for the week:
1. SIU Team Conference Room D324
2. Colorectal Team Conference Room D228
3. Springfield Clinic Team Conference Room D219
4. StJ Team (rotating attending) Conference Room G010
The Chief of the service will present cases for the team and faculty.
This conference is a monthly conference, held on the first workday Monday of each month at 8:00 AM, and will start on Monday, September 12, 2005 for the academic year. In general, we would like to incorporate the concepts of evidence-based medicine into Journal Club. This will provide an opportunity for you to ask a question, search the evidence in the literature, and find the best appropriate answer that is applicable to your practice. These are skills that you will use throughout your entire career as a surgeon. Prior to each Journal Club meeting, the administrative chief resident (St. John’s) will accumulate a number of pertinent questions that have arisen from any of the educational forums of the residency (rounds, x-ray conference, M/M conference, and didactic sessions). At the first Journal Club in September, the entire group will spend 5-10 minutes discussing the questions and defining which is of such importance that it warrants a Journal Club discussion. The list of questions will be saved and further accumulated for additional discussion at the next Journal Club.
Now that the question has been defined, the assigned group of residents will carefully examine the relevant literature that addresses the question. From this they will develop an evidentiary table that will include the conclusions of up to 10 articles that they have reviewed. For each article, the table will include the author, the title of the article, the class of evidence (I, II, III) and a brief conclusion of the article as it relates to the question. Usually there are about 8-10 relevant articles for each important question that we can ask, and these should be included in the evidentiary table. Of these articles, three or four will be chosen for discussion by the entire group at the upcoming Journal Club. These articles should be given to Elieen Denney, in the General Surgery Resident administrative office, so that they can be distributed to the residents in a timely fashion.
Each of the three assigned residents will discuss one of the chosen articles at the Journal Club, with particular attention to the class of evidence that is presented as well as to the conclusion of the article and how it addresses the question. Because we are very interested in critical assessment skills, the discussion of one of the articles should include an example and a comprehensive definition of one of the important concepts of critical assessment on the attached sheet that can be found in the appendix. For instance, one of the presenters could define and discuss “relative risk reduction” which may have been included in his/her article. Try not to pick a term that has been covered at a previous Journal Club.
This conference starts on Monday, September 19th and will meet weekly at 8:00 AM only alternating with the monthly Journal Club. For each session, a resident and an attending mentor have been assigned the function of leading the discussion. The attending mentor will prepare a bibliography, three discussion cases, and ten questions. All residents are expected to have read the material prior to the conference. Discussion of the topic may be centered on a presentation by the attending or be based on the cases and questions. The faculty mentor will be sent questions on the selected topic used in previous years to review and revise. The assigned resident and mentor should have the questions and any related case material to Eileen Denney, in the General Surgery Resident administrative office, ten days in advance, to allow time for distribution to the residents.
Mortality and Morbidity Conference Weekly M&M conference occur on Thursday mornings at 7:00 AM. The service teams (Trauma, SIU, STJ, Pediatric, Vascular, Colorectal, and Springfield Clinic) will be responsible for the conference on a rotating basis. Cases will be chosen by the senior or chief resident and the typed narrative will be submitted to the Residency Office by Tuesday morning. Send via e-mail attachment to Eileen Denney at firstname.lastname@example.org The responsible resident will present the case along with the x-rays. Discussion will be led by the presenting resident and should include a brief review of pertinent literature concerning the complication and how it could be avoided. This will be followed by an open discussion of the mortality or complication. The presenting resident must submit the CD used for their presentation to the residency coordinator for compliance with the Practice Based Improvement Log. If time permits, interesting cases from the weekly case log can be presented. The presentations should not include lengthy discussion of the disease process but rather focus on the issues related to the complication or mortality. The following types of complications should be considered for presentation:
- All mortalities (within 30 days of surgery) Respiratory distress requiring intubation
- Unexpected returns to the OR Unexpected transfer to the ICU
- Unexpected bleeding episodes Unplanned readmission to the hospital related to the surgical problem
- Retained foreign bodies Delay to OR resulting in morbidity or increased length of stay
- Wound infections (defined in hospital or discovered in clinic) Intraabdominal abcess or soft tissue infection
- Surgical misadventures (resulting in additional or prolonged operation or prolonged length of stay) Surgical specimen pathology differing from clinical diagnosis
- Pneumonias (not associated with ventilators) Unexpected sequella of surgery (anastamotic leaks, vascular occlusions, etc)
- Acute myocardial infarction resulting in prolonged stay Renal failure resulting in nephrology consult
Intermittently, the program director will survey the surgical staff to determine if all appropriate cases are being presented. If these are found, they will be presented at the next scheduled M & M conference.
This conference starts on Thursday, September 15th, at 8:00 AM and will alternate with Surgical Grand Rounds.
For x-ray conference, one service team will be asked to present interesting cases that have been recently encountered. A junior resident will be chosen to interpret clinical information and x-ray results from the cases. The senior resident from the responsible service (Trauma, General Surgery, CT, Pediatrics or Vascular) will direct the conference. Attending input is always welcome.
Grand Rounds will alternate with x-ray conference on Thursday mornings from 8:00-9:00 AM. The first Grand Rounds of the academic year is September 8, 2005. The scheduled topic will be announced the week prior at conferences, on a posted flyer and via e-mail to all SIU faculty, students, residents and staff. Each year, PGY-4 and PGY-5 residents will be asked to give a Grand Rounds which will consist of a presentation of a current topic in general surgery. Two of the Grand Rounds will be devoted to the PGY-2 residents’ presentation on their activities in their practice based learning activities. The remainder dates for presentations at Grand Rounds will consist of SIU surgery faculty and invited visiting professors to present on a topic of interest to general surgery residents.
The Surgical Skills Lab is a major component of the surgical education program for this residency and is one of the most sophisticated labs of this type in the country. The benefits of this learning experience, however, depend on the curriculum and the consistency of the experience. All residents will participate in skills lab sessions, which have been tailored to meet the psychomotor, and operative judgment skills appropriate to their level of training. The schedule of lab activities are included in the appendix.
The residents are expected to be present on time and the reading material should be reviewed prior to the session. Usually, each exercise begins with a short didactic presentation that occurs over lunch. The participants will then complete the goals and objectives of the session.
Attendance at each of these sessions is mandatory. Each participating resident must check with their supervising chief resident well ahead of the scheduled session to make sure that clinical responsibilities are covered.
Some of the learning objectives require independent practice on techniques and procedures. Janet Ketchum, the coordinator of the skills lab will be able to arrange the availability of appropriate equipment for the resident’s use when the skills lab is not otherwise scheduled. Please use the computers in the skills lab only for the activities involved in surgical training.
The program feels that clinical practice is highly dependent on teaching skills directed to patients, colleagues, staff, and student. Near the end of each academic year, the residents in the 2nd and 4th year of training will be provide a two day curriculum to update their teaching skills. This will involve presentations, interactive sessions, and group learning exercises intended improve the skills necessary to teach the junior residents and students in the clinical situation. Attendance is mandatory.
ABSITE On the last Saturday in January, the program will administer the American Board of Surgery In-service Exam. This is a four multiple-choice exam that tests the resident’s knowledge of surgical basic and clinical science. All residents must be available to take this test and no vacations will be allowed at the time it is administered. Scores are available in late March and provide each resident a marker of their performance benchmarked to all of the surgical residents in the country who has taken the exam.
While the ABSITE is not the only assessment of the resident’s cognitive knowledge base, it is a fairly good indicator of the resident’s ability to pass the Qualifying Exam of the ABS. Published reports show that residents who score below the 20th percentile in the ABSITE have a predictable high failure rate on the QE. Therefore, we have set the lowest acceptable limit of performance on this exam at this level. Residents scoring below this will subject to remediation and additional supervised reading and testing schedules during the subsequent year. Continued poor performance may result in probationary status, non-promotion, or dismissal from the program.
In the Spring of each year, the PGY 3, 4, and 5 residents will take an oral exam that is similar to the Certifying Examination of the American Board of Surgery. Each resident will be examined in two 30-minute sessions by two examiners. The purpose of the exam is to define the resident’s clinical approach to common surgical problems and scenarios to make sure that “safe” and effective clinical decisions are made. During each session, the resident will be given four or five clinical scenarios that represent broad areas of clinical surgery including GI, endocrine, oncology, trauma, critical care, breast, hepatic, pancreatic, and vascular areas. Evaluations will determine whether the resident has the skills to pass the CE. Feedback about oral test taking skills will be provided individually after the exam.
(Patient Assessment and Management Exam) Concurrent with the oral exam will be the annual PAME exam to test clinical skills for the PG 3, 4, and 5 residents. Each resident will participate in two encounters in which they will interview and examine a patient with a specific surgical problem. Appropriate laboratory and imaging studies will then be provided, after which the resident will discuss the diagnosis and management plan with the patient. This will be followed by a short oral exam focused on the particular problem. Residents will be evaluated by the patient and faculty in areas of clinical knowledge, interviewing and exam skills, management plan, empathy, and communication skills. Feedback will be provided individually after the exam.
(Objective Structured Assessment of Technical Skills) Technical skills and surgical judgment are important aspects of surgical training and will be tested at each year of training. The OSAT has been developed to test the resident’s ability to perform certain procedures that should be mastered at their level of training. Usually these are skills that have been presented and practiced during skills lab sessions in the previous year. In this exercise, the resident will be asked to perform a procedure within a certain time frame which will be evaluated by the faculty. Feedback will be provided individually after the session. Each resident must show competence in the tested procedures before promotion to the next year. Make-up sessions will be available for those residents who do not successfully complete the task on the first try.
Please check your e-mail and watch the bulletin board for meeting room changes.
The development of technical and surgical skills begins in the surgical skills lab with the organized curriculum. The skills learned in this setting are formally evaluated with the Objective Structured Assessment of Technical Skills (OSATS) administered at the end of both the PGYI and the PGYII year. Surgical skills are subsequently evaluated in the operating room and a program referred to as “documentation of sentinel case proficiency”. Rating instruments for ten commonly performed surgical procedures have been developed, two for each of the five years of residency. Each of the operative rating instruments assesses four items specific to the technical aspects of the procedure, two judgment items, and four global items assessing overall proficiency in operative skills. These instruments completed by the faculty online soon after the operative event allows for both structured feedback on your performance as well as a documentation of proficiency in these sentinel cases. The cases for each PGY level are as follows:
PGY1 Excisional biopsy and open inguinal hernia
PGYII Laparoscopic cholecystectomy and dialysis access graft
PGYIII Colon resection and mastectomy/lumpectomy
PGYIV Carotid endarterectomy and thyroidectomy
PGYV Parathyroidectomy and laparoscopic inguinal hernia repair
When a resident performs one of the above ten procedures at either hospital, an evaluation instrument will be sent to the appropriate faculty member for completion. That evaluation will be available for your review to provide feedback on performance. After you have received feedback on a particular procedure and you are ready to sit for your proficiency evaluation, you must notify the faculty member on the day of the procedure that you wish to receive a proficiency evaluation for that performance. In order to be signed off as proficient in this case you must achieve a 90% rating on this evaluation. It is the resident’s responsibility to assure that they have successfully completed these proficiency evaluations. Satisfactory completion of proficiency evaluations for all ten cases will be required before completion of residency and approval for sitting for the qualifying examination in the board certification process. Advancement to the next level of residency training will require satisfactory completion of proficiency evaluation for at least the two cases below the current level of training. For example, before being advanced from the second to the third PGY year, it will be necessary to have satisfactorily completed proficiency evaluation for the PGYI cases of excisional biopsy and open inguinal hernia repair.
New Innovations is an internet-based residency management system adopted by SIU School of Medicine. It will facilitate scheduling, attendance taking, procedure evaluations, faculty evaluating residents, rotation evaluations, and residents evaluating faculty. It is accessible from any computer with connection to Internet Explorer. The access site for New Innovations is www.new-innov.com/suite , and the Institutional Login is SIU-SOM. Each resident is given their own personal User Name, Password and instructions by Barbara Carter, Residency Coordinator their intern year.
At the end of each month you will be notified via e-mail to evaluate the faculty you have worked with on your rotation using New Innovations. Please complete the evaluations on the faculty as soon as possible, as you will be notified to evaluate faculty on a monthly basis, it is important not to get behind!! The form only takes a few minutes to complete and they are totally anonymous, the faculty will not know who evaluated them. If you have not worked with some of the faculty listed for you to evaluate just check the *NET (not enough time) box, it isn't necessary to open up the evaluation form.
All evaluations, including narrative comments will be strictly confidential. You can access your own evaluations through New Innovations and your Advisor will have access to your evaluations.
The residents are requested by the Medical Student Clerkship to evaluate medical students on their service. You will be given a team evaluation form to complete at the end of the students clerkship.
The Residency program and staff will be evaluated by the residents and faculty on a yearly basis. This is a requirement of the RRC and will help the program make appropriate changes to meet the needs of the residents.